Social Accountability in Health System Governance: A Scoping Review

Abstract

Background:

Social accountability is an important element in health system governance, which is necessary for health system reform and reaching Universal Health Coverage. Understanding the social accountability mechanism and tools will help policymakers to design policies according to the context. We aimed to explore the extent of the application of social accountability in health system governance, its results, challenges, and tools.

Methods:

We conducted a scoping review study, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping review. An inclusive search in bibliographic databases and search engines was done to identify peer review articles and grey literatures, published in English in the range of 2010 to 2021. Search terms were (social accountability), (public accountability), AND (health system).

Results:

Thirty-one records met inclusion criteria from 286 potentially relevant sources, which included 25 peer-review articles and 6 grey literatures. Maternal and child health was the main health subject for social accountability interventions. We identified some social accountability tools to apply at the health facility and community levels. Social accountability has some benefits for the health system and for the community and some challenges to the implementation of social accountability were listed.

Conclusion:

Social accountability improves health system performance. It contains different tools and strategies applied at different levels of the health system. Successful social accountability initiatives that are strategic, multi-interventional, and context-specific can produce good results in health services and social domains.

Introduction

Governance is one of the health system’s building blocks, providing a cornerstone for working the others. According to the Merriam-Webster dictionary, Governance is “the act or process of governing or overseeing the control and direction of something (such as a country or an organization)” (1).

Good governance, which was highlighted in the New Public Management movement, is the proper use of the government’s power in a transparent and participative way, which requires the faithful and good exercise of power, and one of its principles is accountability (2). Accountability is the process of providing the answer to an authorized person for one’s action (3) and social accountability (SA) is a participatory process in which citizens held policymakers, Politicians, and public service providers accountable for their decisions and actions. World Bank defines social accountability as “an approach toward building accountability that relies on civic engagement, i.e., in which it is ordinary citizens and/or civil society organizations that participate directly or indirectly in exacting accountability” (4).

Although social accountability approaches have a long history in the public domain, the integration of social accountability innovations in the health sector is a relatively new phenomenon that has been linked to a wide array of positive outcomes at the health systems level (5) and is considered as an advanced form of participation (6). Nowadays more than ever, social accountability is known as one of the effective levers in health system governance (7) which by involving citizens in the monitoring of the policy process and health services delivery, improves health system performance.

In the World Development Report 1993, the World Bank identified social accountability as one of the important tools for health reform in countries (8) and social accountability has been recognized as a key concept for health care reform since the 1990s mainly in developing countries (9–10).

Social accountability by increasing public participation is one of the determining factors for achieving the goal of Universal Health Coverage (UHC) (11–12) and is an important factor in controlling corruption and preventing the abuse of power in the health system (13).

Over the past decades, social accountability has become a major issue in health research (14). Although there is a variety of pieces of evidence about the impact of social accountability interventions on improving health outcomes, the effectiveness of these interventions depends entirely on the context of countries and how measures are implemented (15–16). The study of social accountability is never neutral, but is specifically about changing the power relations between people and officials, and is inherently a political act (17). Researchers and health system managers should strive to design specific models of social accountability for each culture and community that are feasible and acceptable to the community (18).

In the health sciences, the concept of “social accountability” is used in a confusing manner. Social Accountability in medical education” is widely used and has a different meaning from social accountability in governance (19). The WHO defines social accountability in medical education as “the obligations of medical schools to direct their education, research, and services toward priority health concerns in the community, region, and country they serve (20). In addition, in the research field “Socially accountable research” refers to research that addresses the needs and concerns of society (21). By these definitions, the concept of social accountability in medical education and research is similar to the concept of social responsibility. The Cambridge Business English Dictionary defines social responsibility as the “practice of producing goods and services in a way that is not harmful to society or the environment” (22).

A comprehensive study of different aspects of the application of social accountability in the health system would be helpful for health system policymakers in choosing the best tools, which aligned with their context. Our study goal was to explore the extent of social accountability application in health system governance and to identify its tools, results, and challenges.

Methods

This study has been approved by the Research Ethics Committee, School of Public Health, Tehran University of Medical Sciences with approval ID: IR.TUMS.SPH.REC.1401.032.

This paper draws on the Scoping Review method. Review studies are a group of studies that are widely used in the field of health to produce evidence for the provision of medical services. Reviews are classified into different groups according to their purpose and the process of selecting studies. Scoping reviews are extensively used in the exploration and definition of concepts and their limits. It is an appropriate method to summarize and categorize the results from a variety of studies with different research methodologies and provides a preliminary study about the extent and scope of research in a specific subject (23–24). Scoping review, like systematic review, requires a predefined protocol, although there may be some changes in methods later due to a variety of reasons. Unlike a systematic review, which focuses on just one specific question, it seeks to answer a number of questions (25). We conducted this study, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping review (26).

We sought to answer below questions:

• 1- What are the most used social accountability tools in health systems?

• 2- At what levels of health systems, social accountability tools are applied.

• 3- What are the health problems which social accountability has been used for?

• 4- What are the results of social accountability implementation in the health system?

• 5- What are the challenges of implementing social accountability in the health system?

As for Inclusion criteria, all English records (Peer review articles and gray literature) that have dealt with social accountability (concept, tools, application, models, limitation) in the health system were included. Any records about social accountability in medical education and research irrelevant to our definition were excluded from the study. As for Grey literature, we considered only official reports and statements, and case studies published by valid sources. We used the World Bank definition of social accountability mentioned in the introduction.

The search was done by using the keywords “social accountability”, “public accountability “AND “health system” in databases including PubMed, Scopus, and search engines including Google and Google Scholar in the range 2010 to 2021.

In the initial search, 286 records were found and after examining the titles, 121 records were removed due to duplicity and lack of thematic relevance and validity of the source. Finally, 31 records were reviewed which included 25 articles and 6 gray literature – all official reports- (Fig. 1). The list of reviewed records is available in Table 1.

Fig. 1:

Research diagram based on PRISMA guideline (37)

Table 1:

Details of all reviewed records in this study

the author/s	Year	type of Document	type of study	place of study	Health system problem/s	Level of study	SA Tool/s	Result/s
Carolyn Blake et al (38).	2016	Article	Quantitative before and after study	Ghana	Limiting access to emergency maternity and newborn care services	Health facilities (hospitals, clinics, health centers) and at the community level	score card	Improving services/developing a culture of accountability, increasing social participation, transparency and improving accountability lines among policymakers
Mashira et al (39).	2015	Report	Review	Kenya	Low quality of health services and poor governance in the health system	community level	Dissemination of information, community participation and handling of complaints / Citizen report cards	Increasing the use of facilities, improving the trust to the health system, improving performance, Community sensitivity Governance
Gagan Gurung et al (10).	2020	Article	Qualitative thematic analysis	Nepal	problems in Primary care services	primary care centers	Social audit Social audit	Increasing transparency, increasing access, improving quality, improving dialogue between providers and the public The mechanism of punishment and encouragement did not improve
Pieterse (40).	2019	Report	mixed methods to comparative analyses	Sierra Leone	Fragile social environment Lack of proper access to services High price of services Low quality of service	health centers	Non-financial gifts	Improving the interaction between service providers and consumers, improving quality and increasing access to services, and increasing the legitimacy of governance Combined interventions include service quality circle, participatory monitoring and evaluation
Kanang Kantamaturapoj (12).	2020	Article	Case report	Thailand	Weak governance	Policy level	Approval of social accountability law, public hearing, establishment of complaint handling mechanism, answering phone, Establishing the National Board of Health Protection, National Health Assembly	People’s voices are heard Actions to improve problems, respond to people’s needs
Argau et al (9).	2021	Article	A before and after intervention	Ethiopia	High mortality of mothers and babies	health center	Social scoring card	Improving the responsiveness of employees and improving the use of health services Increasing people’s participation in programs
Boydell (41).	2020	Article	Exploratory research - descriptive case study	Uganda	Improper provision of pregnancy prevention services in a gendered and sensitive environment	Area level	social conversation, Social scoring card	Improving communication between the community and the health system, empowering citizens, responding to providers and improving access to services
Mafuta et al (42).	2015	Article	Exploratory-qualitative research	Congo	High maternal mortality rate	Region	Social associations, health committees
Lodenstein et al (6).	2017	Article	A comparison between cases	Congo, Benin, Guinea	Low quality of primary health care	Health Center	Establishment of health facilities committee health facility committees	Improving the quality of care, high level of dialogue between providers and the community, regulation, involvement of high-level officials
Mukesh Hamal (29).	2018	Article	Qualitative	India	maternal Mortality	Region	monitoring by the community, Community participation, establishment of district health committee, establishment of village health council	Improving the interaction between society and the health system, improving access to maternal health services
Francisco Feruglio (43).	2018	Article	Qualitative	India	Rural health and nutrition	Region	Mothers’ committees, village health and health committee, self-help groups
Lodenstein et al (35).	2019	Article	Qualitative	Malawi	General performance of the health center	Health centers	Health Committee	bridge health system Communication between committee members and parent providers
Nadia Butler (44).	2020	Article	Qualitative	Malawi	Pregnancy health and children’s health	National and regional	National and regional dialogue forum	Establishing communication between the community and officials, better response of providers Improving services, improving health infrastructure
Stephanie Topp (31).	2018	Article	Qualitative	Zambia	Health of prisoners	Health centers	Establishment of Prisoner Health Committee	Improving access and quality of services, empowering prisoners and improving the way prisoners speak about health services, improving relations between prisoners and prison officials, increasing mutual trust
Sarah Bennett (18).	2020	Editorial	Case Study	Bangladesh and Uganda	Justice and inclusion of health services	Community level	Scoring cards	Increasing resources available to health, improving health services, improving communication between service providers and the community.
Vicki Boydell (45).	2018	Article	hybrid	Uganda	Pregnancy health and family planning	Community level	Community capacity building	Improving health indicators, improving the quality of care, building trust in health providers, increasing political capabilities, involving officials in the programs.
Dauphin Agaba (46).	2021	Article	Document review	Uganda	Maternal health	Community level	Raising awareness, building capacity, monitoring the situation with community dialogue, creating corrective mechanisms,	Reducing maternal mortality
Nahiton Nahar (30).	2020	Article	narrative literature review	Low-income and middle income countries	health system	Community level	transparency charter of people’s rights, hospital committees, social audit, scoring cards, Community participation (people’s committees, civil institutions)	Improving monitoring, mobilizing resources, improving services, communication between service providers and people
Elizabeth Lodenstein (47)	2017	Article	realistic approach to review	Low-income and middle income countries	health system	Community level	Collecting people’s opinions (complaints, joint meetings, grading) Provider training, participatory planning, intervention of political parties	Improving services and access, mutual respect and interaction between service providers and receivers,
Sara Gullo (48).	2017	Article	A cluster randomized controlled trial	Malawi	reproductive health	Community level	Scoring card	Improving health services, increasing cooperation between people and providers
Igor Franstik (5).	2021	Article	Semi-experimental intervention	Tanzania	Health center performance	Health Center	Strengthening the civil institution for supervision	Improvement of service delivery, no change in the infrastructure that is beyond the authority of the center
Tom Kirk (49).	2017	Report	Case Study	Pakistan	Reproductive health, mother, baby and child	Community level	Empowering, organizing people and facilitating accountability	Increasing health news in the media, forming popular organizations and participating in health decision-making institutions and participatory planning, increasing health resources.
Netra Eng (50).	2015	Report	A qualitative case study	Cambodia	Health system performance	Community level	Empowering communities, forming public institutions and data transparency	Service improvement
Sangeeta Mecwan (32).	2021	Article	Case Study	India	Disabled people, mental patients and gender disorders	Community level	Organizing and empowering youth and adults, creating advisory committees at the village level, establishing communication between the presenter and the youth	Increasing knowledge, strengthening the role of support groups in changing social norms, social monitoring, increasing people’s participation,
Bart Jacobs (51).	2020	Article	Longitudinal comparative study	Cambodia	Use of free health services	Community level	Increasing community participation in decision-making	Increasing the use of free public health center services
Martha Schaaf (14).	2018	Thesis	Descriptive case study	Columbia	Unofficial payment	Community level	Training, access to complaint mechanisms, elimination of complaint risks,	Reduction in payment in study participants and no reduction in the community
Susan A. Pappa (52).	2013	Article	Case Study	India	Pregnancy health	Community level	Establish local women’s forum, media, and elected representatives with health service providers	Creating a need, increasing communication between providers and people, and sensitizing community leaders, increasing critical awareness, increasing social capital and reducing social distance.
George Danhondo (15).	2018	Article	Systematic review	Africa	health system	Community level	Health committee, scoring card, citizen report card, citizens charter,
Adweeti Nepal (53).	2020	Article	Analytical review	Nepal	Community level	Maternal health services	Social audit, prenatal care, citizens charter, scoring cards, complaint registration method, people’s committees, formation of people’s institutions.	Improving the quality of services, improving the responsiveness of the health system, strengthening community ownership, eliminating injustices, and increasing influence on policies.
Eric Mafuta et al (54).	2017	Article	Elite Panel - Qualitative Content Analysis	Congo	Maternal health services	Community level	Creating a formal system for expressing people’s opinions, creating dialogue sessions between providers and recipients, and increasing the responsiveness of providers
Victoria Boydell (55).	2014	Report	Realistic review		Family planning and reproductive health		Participatory budgeting, public budget tracking, citizen reporting card, social audit, Charter of citizens, health committee, information campaigns, complaint documents,

All records were extracted, reviewed and analyzed by two researchers (M.A, A.N). Any conflict between researchers was removed through discussion.

Results

According to our review, the SA tools were taken to address the health problems as shown in (Fig. 2). The majority of our reviewed documents were published in 2020.

Fig. 2:

The health problems identified for SA interventions

Twenty-two of social accountability tools were used at the community level and 9 at the health facility level (Table 2).

Table 2:

Social accountability tools have been used in the health system

SA implementation level	SA tools
Health facility level	scorecard, participatory decision making, social audit, health committees of health facility
Community level	Information Dissemination, complaint handling processes, scoring and reporting card, social accountability ACT, public hearing, hotline, National Health Assembly, town/village health committees, the establishment of civic institutions, capacity building and empowerment of Citizens, approval of the Charter of People’s Rights, social auditing, participatory budgeting

In 10 cases, only one SA intervention was performed and, in the rest, 21 cases, at least two measures were implemented simultaneously.

Implementation of social accountability measures has created some positive results consisting of Improvement of service quality, increased trust and communication between service providers and the citizens, increasing access to services, improving health infrastructure, increasing transparency, improvement of the legitimacy of the government and empowering the communities. Some Challenges to fully implementing social accountability interventions that were identified in our study are Lack of capacity and commitment in public servants, poor program design, inadequate community participation, corruption, limited resources, citizen fear of being questioned by health officials, context inappropriate tools, Lack of legal obligation, Strong gender norms in the community, power imbalance in community and weak regulatory mechanisms.

There was a byproduct of the study, which was not included in our research questions, but we found that considerable. All of the 31 records were about the social accountability interventions in health systems in low- and middle-income countries (LMIC) and we did not find any article about social accountability in the health systems in upper-income countries (Fig. 3). Although we did not find any reasonable explanation for this issue, we suggest that it is caused by a lack of sense of unaccountability in developed countries and a lack of space for doing research in autocratic high-income countries.

Fig. 3:

Geographical distribution of SA studies

Discussion

Since all the reviewed records were from LMICs, the main health problem that has been considered to address was Maternal and child health, which are problems of LMICs (27). Numerous global experiences show the effectiveness of good governance in developing family planning programs (28) and have improved monitoring and resource allocation, community care, and increased public participation in health systems in LMIC (29).

Another area of frequently used social accountability interventions was access to health care. SA interventions facilitating the interaction between service providers and clients could improve access and health outcomes (30). When the people are able to express their priorities and make policy makers accountable for addressing their needs it will increase access, which could be increasing the working hours of health facilities as well decreasing absenteeism of health workers. It also makes health services more affordable for the community they can use it without any hardship. Our study shows that the social accountability measures not only work in general health settings but also are useful in special conditions like prisons (31) and for vulnerable populations such as people with disability and mental disorders (32).

As health is a fundamental right for any person in any situation, social accountability provides means to involve people in special conditions to defend their rights and have authorities respect their health. It is important to consider that although some conditions restrict people to be active in some areas, health should not be a subject of restriction and all people have the right to answer and ask for accountability.

We found that the majority of SA interventions were taken at the community level included at least two tools. It is important to have a comprehensive approach to social accountability. Single tools approaches have limited outcomes. Successful SA programs are usually planned strategically and have multi-sectorial and multi-stakeholder approaches (33). Fox has distinguished between two approaches to social accountability: Tactical that is limited to one tool, usually for expressing community views that have limited achievements, and the strategic approach which has a broader perspective and uses various tools to create an enabling environment to facilitate the collective action of the people and to coordinate the voice of the people to bring about reform in government (34).

We identified a range of SA tools from scorecard at the facility level to Health Assembly at the national level. Some of the tools were implemented at the health facility level (health committee for health facility) (35) and some at the community level (hotline) and some had implemented at both levels (Score Card). Selecting appropriate tools for implementing SA in a setting is a goal-driven and context-oriented activity. There is no standard and fit-for-all-purpose tool for social accountability. The success of these measures is highly dependent on the context of the country, capacities, information, the range of different actors the independence of the people from power and leadership have been effective (30). Therefore, the study of power relations is important in the analysis of social accountability (36).

Some tools are suitable for increasing community participation and empowerment (health committees of health facilities, community education, and information dissemination) while some are for increasing government answerability (scorecard and national assembly).

According to findings, SA interventions could generate results in the health and non-health sectors. Implementation of social accountability in health systems, in addition to improving health outcomes, will lead to the development of democratic processes in countries and improve the accountability of government. (17). Health system as a part of the wider social system, by direct contact with the community can influence the political culture and be affected by it.

The challenges for successful SA interventions are related to providers (such as Lack of capacity and commitment in public servants, poor program design) and citizens (citizens fear being questioned by health officials), but context is the most important determinant in success and failure of SA interventions. Situational analysis and stockholders mapping before any intervention would help policy makers to make informed choices and prevent any failure during the implementation.

A limitation of our study was lack of access to the full text of some articles because of problems in subscribing to databases.

Conclusion

Social accountability is a means to improve health system governance. It contains different tools and strategies applied at the health facility and community level. Successful SA initiatives, which are strategic, multi-interventional, and context-specific, can generate good results in health services as well as in the social and public sphere.

Journalism Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.